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Bloodborne Pathogen Program Guideline & Exposure Control Plan

City Risk LogoOccupational Health & Infectious Disease

                        Risk Management, Portland, OR                                                                                    06/27/2014


The purpose of this Program Guideline and Exposure Control Plan is to: 

  • Eliminate or minimize employee occupational exposure to blood or certain other body fluids in ways that will result in no cost to employees 

  • Comply with OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030 

  • Comply with Oregon OSHA Bloodborne Pathogens Standard OAR 437, Div 2, Sub Div Z (29 CFR 1910.1030 adopted by reference

Bureaus may adopt the citywide BBP Program or create their own. Please see Attachment L for a Bureau specific BBP Program template

 

Definitions for the Bloodborne Pathogens Program 


Contents:

 

 

Program Administration:

Program Elements

Responsibility 

Procedure or Refereence

Program Administration

 

 

 

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City Risk Occupational Health and Infectious Disease Program (OHIDP) and Loss Prevention (LP), and Bureaus

  • Develop, implement, manage, and maintain the citywide Bloodborne Pathogen (BBP) Program.

  • Ensure policy, program guidelines, and website documents are current and updated annually.

  • Track updates or changes relevant to the program.

Attachment A lists the job classifications reasonably expected to have skin, eye, mucous membrane, or parenteral contact with blood and/or body fluids while performing their job duties. The attachment notes, specific tasks, where applicable

 

Exposure Determination: 

Program Elements

Responsibility 

Procedure or Refereence

Exposure Determination

 

 

 

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Bureaus

  • Bureaus are required to perform an exposure determination to:

    • define which job classifications may be occupationally exposed to blood or other potentially infectious materials

    • if not every position in the job classification is potentially exposed, the tasks where there is potential exposure must be listed

  • Attachment A must be reviewed at least annually or as job tasks change.

Compliance Methods:

Universal Precautions and Hand Washing: 

Program Elements

Responsibility 

Procedure or Refereence

Universal Precautions

Bureaus, Supervisors and Employees  

  • All blood and other infectious material must be treated as infectious. Universal precautions must be taken, regardless of the perceived status of the source individual.

  • Universal precautions are recommended

Hand washing

Bureaus 

  • Hand-washing facilities must be available to employees exposed to blood or other infectious materials.

  • Provide an antiseptic cleanser and clean cloth/paper towels or sterile towelettes.

Hand washing

Supervisors

  • Ensure that employees do the following:

    • Wash hands with soap and water immediately after the removal of gloves

    • Immediately wash any other potentially contaminated skin area with soap and water

    • Wash or flush skin or mucous membranes exposed as soon as feasible following contact

Hand washing

Employees

  • After exposure to infectious material, employees shall use appropriate hand washing procedure:

    • Wash hands with soap and running water for at least 15 seconds

    • Rinse hands under running water

    • Dry hands well with paper towel

    • Use paper towel to turn off faucet; all manually controlled faucets are considered contaminated

    • Dispose of single use towels in designated waste containers

    • Hand cream may be applied after frequent hand washing

Engineering and Work Practice Controls:

Program Elements

Responsibility 

Procedure or Refereence

Engineering Controls

Supervisors, City Risk Occupational Health & Infectuous Disease Program (OHIDP) 

  • Engineering controls are used to eliminate or minimize employee exposure.

  • An annual assessment is performed to identify, evaluate, and select engineering and work practice controls (includes safer medical devices).

  • Attachment B may be used as a template form for the assessment

Personal Protective Equipment (PPE): 

Program Elements

Responsibility 

Procedure or Refereence

Appropriate PPE

Bureaus

  • Provide a variety of PPE to employees for use on the job.

  • PPE is chosen based on the exposure to blood or other infectious materials and may include:

    • gloves (hypoallergenic, powderless)

    • gowns, laboratory coats

    • face shields, masks

    • eye protection

    • mouthpieces, resuscitation bags, pocket masks, other ventilation devices

  • If an employee declines to use PPE, in rare and extraordinary circumstances, an investigation of the incident must be performed (Attachment C).

Appropriate PPE

Supervisors

  •  Ensure that the employees use appropriate PPE.

Appropriate PPE

Employees

  • Wear appropriate PPE when infectious material may be present.

  • Latex, vinyl, or nitrile gloves shall be worn when an employee will have hand contact with:

    • blood

    • other potentially infectious materials

    • mucous membranes

    • when handling or touching contaminated items or surfaces

PPE Cleaning, Laundering, and Disposal 

 

 

 

 

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Bureaus, Supervisors, and Employees 

  • All PPE will be cleaned, laundered, and/or disposed of by the City. All repairs and replacements will be made by the City.

  • All garments, penetrated by blood or other potentially infectious material, shall be removed immediately or as soon as possible. All PPE will be removed prior to leaving the work area.

  • PPE will be discarded if cracked, peeling, torn, punctured or exhibit signs of deterioration or when the ability to function as a barrier is compromised.

  • When PPE is removed, it shall be placed in an appropriately designated area or container for storage, washing, decontamination, or disposal. 

Hazard Communication: 

Program Elements

Responsibility 

Procedure or Refereence

Hazard Communication 

Bureau 

  • Bureaus communicate hazards to employees through:

    • labels

    • signs

    • information

    • training

Labels and Signs

Employees

  • Biohazard labels will be affixed to:

    • containers of regulated waste or other potentially infectious materials

    • other containers used to store (i.e. refrigerators or freezers), transport or ship blood or other potentially infectious materials (i.e. sharps containers)

  • The universal biohazard symbol and color coding will be used.

Training 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Bureau and City Risk OHIDP 

  • Training requirements:

    • initial BBP training when assigned tasks where occupational exposure may occur

    • annual refresher training is required

    • additional training when changes affect the employee's potential exposure (this training may be specific to the modifications)

  • The training will include:

    • An accessible copy (hard copy or electronic) of the regulatory text of this standard and an explanation of its contents

    • A general explanation of the epidemiology and symptoms of bloodborne diseases

    • An explanation of the modes of transmission of bloodborne pathogens

    • An explanation of the City ofPortland's Bloodborne Pathogen Exposure Control Plan, it’s location on the City’s website and a method for obtaining a copy of the written plan

    • An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials

    • An explanation of the use and limitations of methods that will prevent or reduce exposure; for example: engineering controls, work practices and PPE

    • Information on the types, use, location, removal, handling, decontamination and disposal of PPE

    • An explanation of the basis of selection of PPE

    • Information on the Hepatitis B vaccine, including information on is efficacy, safety, method of administration, the benefits of being immunized, and that the immunizations will be offered at no charge to the employee

    • Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials

    • An explanation of procedures to follow if an exposure incident occurs, including the method of reporting and medical follow-up

    • Information on the evaluation and follow-up required after an employee exposure incident

    • An explanation of the signs, labels and color coding systems

    • Time for questions and follow-up 

Contaminated Item Cleaning and Regulated Medical Waste Disposal: 

Program Elements

Responsibility 

Procedure or Refereence

Contaminated Sharps

Employees

  • Contaminated needles will not be bent, recapped, removed, sheared or purposely broken. Needles shall be put in sharps containers.

  • Any broken glassware, which may be contaminated, will not be picked up directly with the hands. It will be cleaned up using a broom/brush and dustpan and disposed of in a sharps container.

Contaminated Equipment

Employees

  • Employees must notify their supervisor of:

    • contaminated tools

    • contaminated equipment

Contaminated Equipment

Supervisors 

  • Ensure that equipment, which has become contaminated with blood or other potentially infectious materials, be cleaned prior to returning it to service.

  • Tools and equipment can be cleaned by washing them in a fresh bleach solution of one (1) part bleach to nine (9) parts water. "Fresh" means mixed within the prior 24 hours or less.

Laundry Procedures

Bureau, Employees 

  • Protective gloves are to be worn at all times when dealing with contaminated laundry. Laundry soiled with blood or other potentially infectious materials will be handled as little as possible. Such laundry will be placed in appropriately marked (biohazard labeled and/or color-coded red) bags at the location where it was used. Such laundry will not be sorted or rinsed in the area of use.

  • Laundry will be picked up by the bureau’s contracted laundry service or otherwise appropriately laundered. Employees will not take contaminated laundry home.

Waste Disposal Containers

 

 

 

 

 

 

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Bureau, Employees 

  • All sharps containers will be disposable. Contaminated sharps shall be discarded immediately or as soon as possible in containers that are closeable, puncture resistant, and leak proof on sides and bottom. Sharps containers will be labeled or color-coded.

  • The containers shall be maintained upright throughout use and replaced routinely and not be allowed to overfill.

  • Other Regulated Medical Waste will be in closable, leak-proof, labeled and color-coded, containers.

  • Disposal of all regulated waste shall be in accordance with the applicable federal, state, and local regulations 

Sample Storage, Transportation or Shipping:  

Program Elements

Responsibility 

Procedure or Refereence

Blood Samples

 

 

 

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City Risk OHIDP 

  • Blood samples are placed within a secondary container that prevents breakage and possible leakage during the handling, storage, and transport.

  • The container must be labeled, color-coded, and closed prior to shipping.

Hepatitis B Immunizations and Post-Exposure Evaluation, Management, and Follow-Up: 

Program Elements

Responsibility 

Procedure or Refereence

General 

City Risk OHIDP 

  • The Hepatitis B shot series is available to all employees with:

    • occupational exposure and

    • post-exposure follow-up

  • City Risk’s OHIDP will ensure that all medical evaluations and procedures, management and follow-up are:

    • Made available at no cost to the employee

    • Made available to the employee at a reasonable time and place

    • Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed health care professional

    • Provided according to the recommendations of the U.S. Public Health Service

Hepatitis B Immunization

 City Risk OHIDP

  • The OHIDP will provide BBP training and Hepatitis B shots for exposed employees.

  • Any employee who begins the shot series under the City's program will be able to complete the series at the City's expense as long as they are a City employee.

  • Hepatitis B shots will be made available:

    • After the employee has received the bloodborne pathogen training

    • Within 10 working days of initial assignment to tasks where an occupational exposure to blood or other potentially infectious material is reasonably expected to  occur, or

    • To all employees who have occupational exposure unless:

      • The employee has previously received the complete Hepatitis B shot series (Documentation must be provided to the OHIDP)

      • Antibody testing has revealed that the employee is immune, or

      • Immunization is contraindicated for medical reasons

Hepatitis B Immunization

 

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 Employees

  •  All employees who decline the Hepatitis B shots shall sign a waiver indicating their refusal, Attachment D.

Exposure Incident Reporting, Evaluation, and Follow-Up:

Program Elements

Responsibility 

Procedure or Refereence

Exposure Incident Procedure

Bureau, City Risk OHIDP, Employee, Third Party Provider

  • If there is possible exposure to blood or other potentially infectious material, the employee should

    • wash and/or flush the exposed area immediately and

    • report the incident to their supervisor 

Exposure Documentation

Bureau, Supervisor, Employee, City Risk OHIDP, Third Party Provider

  • Assess the exposure by following the guidelines for communicable diseases. (See Communicable Disease Guidelines, Attachment E) All Level 3 exposures should be documented and reported.

  • Document the incident using the sample Exposure Incident Report (Attachment F) or a bureau specific report.

  • Call the post-exposure service at 503-721-0529. This line is available 24 hours per day, 7 days a week. Identify yourself as a City ofPortlandemployee; give a call back number and any other pertinent information. The answering service will page the occupational nurse on call.

  • The employee will be called back within 20 minutes for exposure assessment. The occupational nurse will complete the Exposure Worksheet (Attachment G) with information provided by the employee. At this time, the employee will receive an initial assessment of the exposure, recommendations for treatment and/or referral.

  • The employee may seek medical treatment from a physician of their choice.

  • Direct the employee to a confidential evaluation with the OHIDP Nurse in City Risk or the health care provider of their choice.

  • Review all applicable City, Bureau, and Risk policies with employee.

  • Review engineering controls and work practices.

  • Identify personal protective equipment availability.

  • Review possible alternatives with the employee.

  • Send copies of attachments to the OHIDP Manager in City Risk (106/709).

Evaluation and Follow-Up

City Risk OHIDP

  • Document the following:

    • the route of exposure

    • how the incident occurred

    • the source individual, unless identification is not possible or prohibited by state or local law

Collection and Testing of Blood for Infectious Diseases

Third Party Provider

  • The exposed employee's blood will be collected and tested as soon as possible after consent is obtained. (Information Sheet for Body Fluid Exposure, Attachment H)

  • The source individual's blood will be tested as soon as possible, after consent is obtained, to determine the possibility of HBV, HCV, or HIV infection

    • If consent is not obtained, City Risk will establish that legally required consent cannot be obtained

    • Other alternatives for consent may be pursued at that time if source testing will effect the continued treatment of the exposed employee

    • If the source individual is already documented to be infected with HBV, HCV, or HIV, testing need not be repeated

  • Results of the source individual's testing will be made available to the exposed employee. The employee will be informed of laws and regulations about disclosure of the identity and infectious status of the source individual. 

Information Provided to the Health Care Professional

Bureau, City Risk OHIDP 

  • A designee within the Bureau will ensure that the health care professional responsible for the employee's post-exposure evaluation is provided with the following:

    • A copy of 29CFR 1910.1030 (will already be provided to the following institutions: Portland Adventist, Emmanuel, OHSU, and Good Samaritan Hospitals)

    • A written description of the exposed employee's duties as they relate to the exposure incident

    • Written documentation of the route of exposure and circumstances under which exposure occurred

    • Results of the source individuals blood testing, if available

    • All medical records relevant to the appropriate treatment of the employee (the employee's vaccination status is maintained by the OHIDP in City Risk)

  • City Risk may give information to the employee's medical provider. 

Health Care Professional’s Written Opinion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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City Risk OHIDP 

  • City Risk OHIDP will provide the employee:

    • a copy of the health care professional's written opinion within 15 days of the evaluation

    • Post-Exposure Evaluation, Attachment I

  • The written opinion on Hepatitis B is limited to:

    • whether or not post-exposure HBV immunization should occur and

    • if the employee has received the vaccine

  • The opinion concerning post-exposure evaluation must include and is limited to the following:

    • Statement that the employee has been informed of the results of the evaluation

    • Statement that the employee has been told of any medical conditions resulting from the exposure that require further treatment or evaluation

    • Any other findings are not to be included in this report

Recordkeeping:

Program Elements

Responsibility 

Procedure or Refereence

Medical Records

City Risk OHIDP

  • These records shall be kept confidential and must be maintained for at least the duration of employment plus 30 years.

  • The records shall include the following:

    • Name and social security number (may be the last four digits in the following form: XXX-XX-1234) of the employee

    • Copy of the employee's Hepatitis B immunization status, including the dates of immunizations

    • Copy of all results of examination, medical testing and follow-up procedures, including the healthcare professional’s written opinion

    • Copy of information provided to the health care professional, including a description of the employee's duties as they relate to the exposure incident and documentation of the route of exposure and circumstances of the exposure

Training Records

Bureau 

  • Training records will be maintained for three years from the date of training.

  • The following information will be documented:

    • The dates of the training sessions

    • An outline describing the material presented

    • The names and qualifications of person conducting the training

    • The names and job titles of all persons attending the training sessions 

Sharps Injury Log

Bureau

  • Confidential log must report injuries from contaminated sharps.

  • City Risk OHIDP may request copies of these logs.

  • The log must include (Attachment J includes a sample log):

    • The type and brand of device involved in the incident

    • The department or work area where the incident occurred

    • An explanation of how the incident occurred 

Housekeeping

 

 

 

 

 

 

 

 

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City Risk OHIDP 

  • Work area is to be maintained in a clean and sanitary condition. Equipment and work surfaces are to be cleaned and decontaminated:

    • Immediately or as soon as feasible when contaminated with potentially infectious materials

    • At the end of a work shift if they have been contaminated since last cleaning

    • Per the frequency required by the written schedule

  • Attachment K provides a Cleaning and Decontamination Schedule Template